HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 05/03/2017i
1 I F
1s. 4 Community Development
r 281 N. College Ave.
Ort. Collins Pa Box 580
Fort Collins, CO 80522
i 970.416.2740
970.224.6134(fax)
`` /cgov.com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: g;�o �)OI Permit #: 1UZ717 Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician,Name (print): Company Cam, vl-ct CAI*.jAj , 7
Technician Signature: Date 5-11311,7
Appliance Tested:
Appliance Replaced: l
Worst Case Conditions:
Spillage Duration (in seconds): co _
Pass ✓ Fail
Carbon Monoxide (parts per million): / f
Date Tested:
Natural Conditions: ds): Carbon Monoxide (parts per million):
�a/
Spillage Duration (in 7Fail
/
Pass Date Tested: -L53
(Failed test requires corrections until test passes under Natural Conditions)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I certify that I am the legal owner of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst -case conditions. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature Date
CST:replacementh)atural-draft/4.25.12